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Journal of Ultrasound (2008) xx, 1e5

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12 Ultrasound-guided injection of botulinum toxin 74

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A in the treatment of iliopsoas spasticity 76
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L.M. Sconfienza a,*, N. Perrone a, F. Lacelli b, C. Lentino c, G. Serafini b

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21 Di.Me.S. Sezione di Radiodiagnostica, Università degli Studi di Genova, Genova, Italy 83
22 Dipartimento di Diagnostica per Immagini e Alta Tecnologia, AO Ospedale Santa Corona, Pietra Ligure (SV), Italy 84
Dipartimento di Recupero e Riabilitazione funzionale, AO Ospedale Santa Corona, Pietra Ligure (SV), Italy 85
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28 KEYWORDS Abstract Purpose: Intramuscular injection of botulinum toxin A (BTX-A) is a common treat- 90
29 Botulinum A toxin; ment for iliopsoas muscle spasticity, but it is not easy to position the needle in this muscle 91
30 Interventional without guidance. We describe an ultrasound-guided technique for the intramuscular injection 92
31 ultrasonography; of BTX-A to treat spasticity of the iliopsoas muscle. Its effectiveness was assessed in 10 pa- 93
32 Injection; tients. 94
33 Iliopsoas muscle; Method and materials: The ultrasound-guided technique for BTX-A injection was used on 10 95

34 Cerebral palsy. patients. The needle was inserted into the muscle belly at an angle of 45 along the longitu- 96
35 dinal axis of the muscle when the patient’s condition allowed. 97
36 Results: In all cases, the iliopsoas muscle was easily identified and both the iliac and psoas 98
37 components were assessed. Introduction of the needle and drug injection was carried out en- 99
tirely under ultrasonographic guidance. The procedure was successful in all patients, even in

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39 those with a high-grade spasticity, and general anesthesia was not required. 101
40 Conclusions: This ultrasound-guided technique allows accurate guidance for the injection BTX- 102
41 A, and it can be considered as an alternate supportive therapy in patients with spasticity and 103
42 dystonia. 104
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44 Sommario Obiettivi: L’iniezione intramuscolare di tossina botulinica A (BTX-A) per il tratta- 106
45 mento della spasticità del muscolo ileopsoas è tecnica consolidata, ma è gravata da un’alta 107
46 difficoltà nel preciso posizionamento dell’ago. Scopo del nostro lavoro è descrivere una tecnica 108
47 ecoguidata per l’introduzione intramuscolare di tossina botulinica nel trattamento della spas- 109
48 ticità del muscolo ileopsoas e valutare l’efficacia terapeutica di questa terapia. 110

49 Materiali e metodi: Dieci pazienti con spasticità cronica del muscolo ileopsoas sono stati trat- 111
50 tati mediante inoculazione ecoguidata intramuscolare di BTX-A. L’ago è stato introdotto in 112
51 sede intramuscolare nel contesto del muscolo con un’inclinazione di 45 sull’asse longitudinale 113
52 del muscolo stesso. 114
53 Risultati: In tutti i casi trattati, il muscolo ileopsoas è stato facilmente identificato e distinto 115
54 nelle sue componenti iliaca e psoas. L’intera procedura, sia di introduzione dell’ago sia di in- 116
55 iezione del farmaco nel sito corretto è stata monitorata ecograficamente. La procedura è stata 117
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58 * Corresponding author. Di.Me.S. Sezione di Radiodiagnostica, Università degli Studi di Genova, via L.B. Alberti 2, 16132 Genova, Italy. 120
59 E-mail address: (L.M. Sconfienza). 121
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61 1971-3495/$ - see front matter ª 2008 Published by Elsevier Masson Srl. 123
62 doi:10.1016/j.jus.2008.05.002 124

Please cite this article in press as: Sconfienza LM, et al., Ultrasound-guided injection of botulinum toxin A in the treatment of iliopsoas
spasticity, Journal of Ultrasound (2008), doi:10.1016/j.jus.2008.05.002
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2 L.M. Sconfienza et al.

125 eseguita con successo in tutti i casi, anche in quelli con intensa spasticità, senza ricorrere ad 187
126 alcuna anestesia generale. 188
127 Conclusioni: La tecnica ecografica descritta consente una guida precisa alla corretta inocula- 189
128 zione del farmaco. L’iniezione ecoguidata di BTX-A può essere considerata una terapia alter- 190
129 nativa di supporto nei pazienti con spasticità e distonia. 191
130 ª 2008 Published by Elsevier Masson Srl. 192
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134 capsule as markers, the sonographer can clearly locate the distal 196
Introduction 197
portion of the iliopsoas and the neurovascular bundle, which lies
136 medial to the muscle. 198

137 Botulinum toxin is a protein produced by Clostridium botu- In this study, we used an anterior approach, with the patient in 199
138 linum, which inhibits muscle contraction by transiently a supine position. The preferred site for BTX-A injections is the pre- 200
139 blocking the release of acetylcholine at the neuromuscular insertional segment of the distal portion of the iliopsoas muscle, 201
140 junction. In nature, there are 7 botulinum toxins identified proximal to the myotendinous junction, beneath the inguinal 202
141 with capital letters from A to G. Only 3 of these (toxins A, B, ligament.

and E) are capable of provoking the botulinum intoxication The needle is introduced under US guidance in a caudocranial
142 204
syndrome, also known as botulism. This condition is charac- direction at a 45 angle until its tip is correctly positioned in the
143 muscle. No needle guide was needed. Nevertheless, in patients with 205
144 terized by flaccid paralysis of the striated muscles and 206
severe spasticity, this approach is precluded by the strong hyper-
145 blockade of the cholinergic vegetative functions. The toxin 207
flexion of the thigh. In these cases, the drug should be injected into
146 inactivates certain membrane proteins that are essential the most distal portion of the muscle possible; the needle is inserted 208
for cellular function. This process involves the temporary

147 in the axial plane with a lateromedial orientation. 209
148 inhibition of presynaptic acetylcholine release; conse- US was performed with a Philips iU22 scanner (Koninklijke 210
149 quently its effects are restricted to motor neurons that de- Philips Electronics N.V., The Netherlands) equipped with a 5e2 MHz 211
150 pend on cholinergic transmission (muscular plate, gland convex transducer and a 12e5 MHz high-resolution linear broad- 212
151 innervating cells) [1,2]. Injections of botulinum toxin A band array transducer.
(BTX-A) have been shown to be effective [3e6] in the treat- The study was conducted according to the principles of the
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Declaration of Helsinki of 1964. Informed consent was obtained
153 ment of etiologically diverse types of muscle spasms. Cor- 215
rect placement of the needle within the muscular from all patients.
154 216
155 structure is essential to avoid adverse effects. Moreover, 217
unless one is certain that the toxin has indeed been in- Statistical analysis
156 218
157 jected into the muscle poor clinical outcomes cannot be re- 219

liably attributed to a lack of response to BTX-A [6]. Post-treatment variations in VAS scores were assessed with a non-
158 parametric ManneWhitney U test. We considered P values < 0.05 to 220
159 The purpose of this paper was to describe an ultrasound 221
be statistically significant.
160 (US)-guided technique for the accurate injection of BTX-A 222
161 and to assess the results achieved with this technique in 223
patients with iliopsoas muscle spasticity. Results

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164 In all patients, the US examination allowed easy identifi- 226
Materials and methods
165 cation of the iliopsoas muscle and reliable guidance for 227
166 needle insertion and BTX-A injection. All patients had good 228
We treated 10 patients with spasticity of the iliopsoas muscle
167 responses to the therapy. No peri- or post-procedural 229

caused by infantile cerebral palsy (CP) in 4 cases (2 hemiplegic

168 patients who were ambulatory and 2 nonambulatory patients, 1 di- complications occurred (Figs. 1 and 2). 230
169 plegic and 1 paraparetic; mean age 13  3.56 years); multiple scle- The patients who were ambulatory prior to treatment 231
170 rosis (MS) in 4 cases (all nonambulatory; mean age 44.75  8.85 presented significantly improved hip kinetics and spatio- 232
171 years); or spinal-cord trauma in 2 cases (both nonambulatory pa- temporal walking parameters. The nonambulatory MS 233
172 tients; mean age 32.50  2.12 years). Spasticity was assessed patients with postural alterations before the treatment 234

173 with a Visual Analogue Scale (VAS) before and 40 days after the pro- showed significant improvement in the posture that facil- 235
174 cedure [7]. itated nursing care. 236
175 After the neuromuscular blocking, patients underwent a 4-week Patients with spinal lesions experienced remarkable 237
rehabilitative treatment.
176 reductions in muscle spasticity, which translated into less 238
We used a 22-gauge spinal needle to inoculate 150 units of BTX-
177 pain, better sleep (which was no longer interrupted by 239
A with a single injection (Dysport, Ipsen SA, France). The toxin
178 was injected only when the needle was located in the correct spastic contractions), and a better quality of life. 240
179 position. All patients presented significantly reduced muscle tone 241
180 with significant decreases (P < 0.01) in the VAS score (Table 242
181 Technique 1), increases in the passive range of motion of the hip, and 243
182 a reduction of spasms. 244
183 The iliopsoas is a deep muscle that is closely associated with the None of the patients required a second injection to 245
184 neurovascular bundle of the lower limb. For this reason, US achieve full therapeutic effects. 246
185 guidance is mandatory for correct placement of the needle prior Rehabilitative treatments proved to be easier to admin- 247
186 to the injection of BTX-A. Using the femoral head and the articular ister after this treatment. 248

Please cite this article in press as: Sconfienza LM, et al., Ultrasound-guided injection of botulinum toxin A in the treatment of iliopsoas
spasticity, Journal of Ultrasound (2008), doi:10.1016/j.jus.2008.05.002
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Us-guided injection of BIX-A 3

249 spasticity, and cerebral palsy [4,5,9,10]. More recent appli- 311
250 cations include neuromuscular blockade of inappropriately 312
251 contracted sphincters (e.g., associated with spasmodic dys- 313
252 phonia, anal spasms, vaginism, achalasia, and altered ocu- 314
253 lar movements such as those of nystagmus) [11e13] and of 315
254 exocrine glands affected by autonomic hyperactivity (as in 316
255 hyperhidrosis or sialorrhea) [14,15]. The toxin has also been 317
256 successfully used in the treatment of pain associated with 318
257 the myofascial pain syndrome, lumbar back pain, mi- 319
258 graines, and tension headaches [16]. It is also widely used 320
259 to eliminate facial wrinkles [17]. 321
260 Though botulinum toxin is considered the most powerful 322

261 poison in nature (a few nanograms are enough to kill an 323
262 adult man), the therapeutic window is definitely safe: 324
263 doses used in daily practice are 50e100 times lower than 325
264 the lethal dose. Moreover, central nervous system side 326
265 effects are unlikely since the toxin does not cross the 327

266 brain-blood barrier. The widespread use and large-scale ap- 328
267 plication of this toxin are basically justified by the absence 329
268 of reports of significant side effects, the reversibility of its 330
Fig. 1 Ultrasonographic image obtained with a linear probe
269 action, and the fact that the treatment can be repeated if 331
(12e5 MHz). The needle (black arrows) has been inserted into
270 necessary. BTX-A is preferred over surgical approaches be- 332
the psoas muscle (*). F Z femoral head.
We did not perform any ultrasound assessments of the
maximum level of efficacy of the injection, which was
achieved 20e29 days after the injection (mean 24.1  1.21
DP cause it can be used to produce calibrated states of muscle
relaxation, and it does not produce permanent lesions. Pa-
tient satisfaction is usually high, and the cost of treatment
is considerably lower than that based on conventional drug
therapy [18]. In most cases, the effects of BTX-A therapy
275 337
276 days). All patients were followed for 6 months after the are evident for 2e3 days after the injection, and the max- 338
treatment monthly US scans. In all cases, satisfactory mus-
277 imum effect is observed after about 3 weeks. They last up 339
278 cle relaxation was maintained for 3 months; in 4 patients to 3e4 months. After this period, the chemical denervation 340
279 the effects lasted 4 months, and 2 experienced beneficial induced by the toxin is hindered by spontaneous neo- 341
280 effects for 6 months. innervation. Some patients (2e3%) do not respond to the 342
281 therapy, and 5e7% develop an antibody response to the A 343

282 Discussion serotype of the toxin. In these cases, serotype B toxin is 344
283 used. Its clinical effects are the same as those of BTX-A, 345
284 Clostridium botulinum was discovered by Emile Pierre van but the doses used are different [19]. 346
285 Ermengem in 1895. The therapeutic use of botulinum toxin Spasticity of the iliopsoas muscle can cause several 347
problems in patients undergoing rehabilitative therapy. In

286 was first proposed in 1973 by Scott et al., who used the se- 348
287 rotype A toxin to correct strabismus [8]. Injections of botu- patients who are ambulatory, it alters hip kinematics during 349
288 linum toxin are currently used to treat primary and walking, hindering the physiologic extension that occurs 350
289 secondary dystonia, post-stroke and post-traumatic during the central-late terminal period of the step. In 351
290 nonambulatory patients, iliopsoas spasticity can cause the 352
291 non-ambulatory patient to assume an incorrect posture in 353

292 the wheelchair, and this can lead to myotendinous retrac- 354
293 tion that is difficult to reduce. These problems are even 355
294 more serious if the spasticity also affects other muscle 356
295 groups or both lower limbs. 357
296 Different techniques for the treatment of iliopsoas 358

297 spasticity with BTX-A have been proposed. Ward [20] used 359
298 palpation alone to position the needle (with an anterior 360
299 or posterior approach). Willenborg et al. [21] employed 361
300 US to locate the muscle and verified the correct position 362
301 of the needle by electrostimulation. The computed tomog- 363
302 raphy-guided technique described in 2000 by Porta et al. 364
303 had several disadvantages, including high costs, long exam- 365
304 ination times, use of ionizing radiation, and the need for se- 366
305 dation especially in young patients [22]. In 2003, Westhoff 367
306 et al. [6] described a US-guided technique with an anterior 368
307 approach, which allowed the needle to be positioned 369
308 Fig. 2 Ultrasonographic image obtained with a convex probe quickly, safely, and without the use of ionizing radiation. 370
309 (5e2 MHz). The needle (black arrows) has been inserted into Our experience indicates that the choice of whether to 371
310 the psoas muscle (*). F Z femoral head. use a convex or linear US probe depends exclusively on the 372

Please cite this article in press as: Sconfienza LM, et al., Ultrasound-guided injection of botulinum toxin A in the treatment of iliopsoas
spasticity, Journal of Ultrasound (2008), doi:10.1016/j.jus.2008.05.002
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373 Table 1 Characteristics of the 10 patients with iliopsoas Conflict of interest 435
374 spasticity
375 The authors have no conflict of interest. 437
376 Age Cause of VAS (T Z 0) VAS Z 40 438
377 spasticity days 439
378 1 8 CP 7.5 3.1 References Q1 440
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Please cite this article in press as: Sconfienza LM, et al., Ultrasound-guided injection of botulinum toxin A in the treatment of iliopsoas
spasticity, Journal of Ultrasound (2008), doi:10.1016/j.jus.2008.05.002
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Us-guided injection of BIX-A 5

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Please cite this article in press as: Sconfienza LM, et al., Ultrasound-guided injection of botulinum toxin A in the treatment of iliopsoas
spasticity, Journal of Ultrasound (2008), doi:10.1016/j.jus.2008.05.002